Rate of Preventable Early Unplanned Intensive Care Unit Transfer for Direct Admissions and Emergency Department Admissions

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1 RESEARCH ARTICLE Rate of Preventable Early Unplanned Intensive Care Unit Transfer for Direct Admissions and Emergency Department Admissions AUTHORS Jennifer Reese, MD, a Sara J. Deakyne, MPH, b Ashley Blanchard, MD, c Lalit Bajaj, MD, MPH d a Sections of Hospital Medicine and d Emergency Medicine, Department of Pediatrics, University of Colorado, Children s Hospital Colorado, Aurora, Colorado; b Research Informatics, Children s Hospital Colorado, Aurora, Colorado; and c New York Presbyterian Morgan Stanley Children s Hospital, Columbia University Medical Center, New York, New York KEY WORDS transfers, direct admission, ICU, quality improvement ABBREVIATIONS ACM: admitting case manager ED: emergency department NOC: Network of Care OR: operating room ORRQIP: Organizational Research Risk and Quality Improvement Panel PDR: Patient Disposition Review PEWS: Pediatric Early Warning Score doi: /hpeds These data were presented in a platform presentation at the Pediatric Academic Society; May 1, 2012; Boston, MA. Address correspondence to Jennifer Reese, MD, Section of Hospital Medicine, Children s Hospital Colorado, Box B302, E 16th Ave, Aurora, CO jennifer.reese@ childrenscolorado.org HOSPITAL PEDIATRICS (ISSN Numbers: Print, ; Online, ). Copyright 2015 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. abstract BACKGROUND AND OBJECTIVE: Appropriate patient placement at the time of admission to avoid unplanned transfers to the ICU and codes outside of the ICU is an important safety goal for many institutions. The objective of this study was to determine if the overall rate of unplanned ICU transfers within 12 hours of admission to the inpatient medical/surgical unit was higher for direct admissions compared with emergency department (ED) admissions. METHODS: This was a retrospective cohort study of all unplanned ICU transfers within 12 hours of admission to an inpatient unit at a tertiary care children s hospital from January 2010 to December Proportions of preventable unplanned transfers from the ED and from direct admission were calculated and compared. RESULTS: Over the study period, there were a total of admissions; 279 unplanned ICU transfers occurred during the study period of which 101 (36%) were preventable. Preventable unplanned transfers from each portal of entry were calculated and compared with the total number of admissions from those portals. The portals of entry evaluated included admissions from our internal ED versus all outside facility transfers. The rates of early unplanned transfer (per 1000 admissions) by portal of entry were 3.50 for direct admissions and 3.18 for ED. There was no difference between direct admissions and ED admissions resulting in preventable unplanned transfers to the ICU (P =.64). CONCLUSIONS: Rates of unplanned ICU transfers within 12 hours of admission to an inpatient unit are not higher for direct admissions compared with ED admissions. Further studies are required to determine clinical risk factors associated with unplanned ICU transfer after admission, thus allowing for more accurate initial patient placement. Triaging patients to the appropriate level of care and escalating treatment of patients with evolving critical illness are key components to hospital medicine. In the pediatric setting, it has been shown that ward admissions to the ICU have higher odds of mortality than ICU admissions from the emergency department (ED). 1 Additionally, within the pediatric population, patients admitted to an ICU from a referring hospital were more ill than patients admitted from within the institution. 2 Unplanned ICU transfers have been used as a patient safety measure and quality indicator by many organizations 3 and also represent a substantial increase in resource utilization. 4 27

2 The goal in evaluating unplanned transfers is to identify potentially preventable cases, to develop interventions to help reduce adverse outcomes, such as increased hospital length of stay and increased mortality rates. A recent study in the pediatric literature aimed to describe the clinical characteristics of children who require ICU transfer by a retrospective review of unplanned early ICU transfer at 1 institution. Clinical characteristics that accounted for a large proportion of early unplanned ICU transfer include age <1 year, boys, and those with respiratory complaints. 5 At the study institution before this study, the general perception was that direct admission from a location other than our hospital s ED or operating room (OR) to the inpatient unit was thought to be a risk factor for unplanned transfer to the ICU. This assumption was made because these children may not be as thoroughly evaluated or accurately triaged by providers unfamiliar with our institution s patient placement criteria if they are coming from a location outside of our institution, or that their clinical status may have deteriorated en route if they are coming from one of our regional sites. The impetus for this study was due to the lack of data at our own institution to support the assumption of direct admissions as a risk factor for unplanned transfer to the ICU, in addition to the limited research in the pediatric setting on this topic. This study aimed to determine if there was a significant difference in the rate of early unplanned ICU transfer associated with direct admission, compared with patients admitted from our ED to the inpatient unit. METHODS This study was approved by the study institution s Organizational Research Risk and Quality Improvement Panel (ORRQIRP). The ORRQIRP was established by agreement between the academic institution s human subject research review board and the study institution in ORRQIRP is sanctioned by the institutional review board to review quality improvement project proposals to determine if they do not meet criteria for human subjects research. We conducted a retrospective cohort study of all early transfers to the ICU from an inpatient unit at our academic, tertiary care children s hospital, from January 2010 through December The study institution admits patients per year, and during the study period consisted of 300 inpatient beds, 85 of which were ICU (including neonatal, pediatric, and pediatric cardiac). For this study, we defined early unplanned transfer as a transfer to the ICU from an inpatient unit within 12 hours of admission to the inpatient unit. Although sources in the pediatric literature suggest a time duration of 24 hours from admission to the hospital as a defi nition of early ICU transfer, 6 a time duration of 12 hours from admission to hospital was selected by institutional agreement. We felt that this time duration would be more likely to capture preventable errors in triage and communication rather than progression of illness. Unplanned was defined as a transfer to the ICU from the inpatient ward that was not expected or previously coordinated (such as a planned ICU admission postoperatively). The Patient Disposition Review (PDR) committee was formed in 2010 to review all cases of unplanned ICU transfer within 12 hours of admission to the inpatient unit. It consisted of nurses and physicians representing inpatient units, ED, pediatric subspecialties, Patient Placement Department, OR, and ICU. A weekly report of all unplanned ICU transfers within 12 hours of admission to the ward was ed to all members of the committee. A designee (nurse or physician) from the originating unit reviewed each of their own unit s cases by using a standardized case review form. The case was briefly presented by the reviewer at the monthly PDR committee meeting, and then the committee discussed whether the unplanned ICU transfer was thought to be preventable or not. This decision was based on consensus of the group, often with additional input from providers involved in the case being solicited by the case reviewer before the meeting. The determination of preventable versus nonpreventable is based on internal criteria of the committee and is not based on other institutions processes or derived from previous studies. The criteria for determining preventable versus nonpreventable included factors that were identified if a different intervention or placement decision made (such as initial placement in the ICU or treatment delivered) would have avoided the ICU transfer. An example of nonpreventable criteria would include unpredictable seizure. An example of preventable criteria would include clearly documented respiratory instability at the time the patient was assigned to the inpatient floor as identified on chart review. The cases that were determined to be preventable were further categorized by the PDR committee as missed diagnoses, misplacement based on patient acuity, ICU census near maximum cap acity, communication failure, or other reasons based on clinical information obtained on chart review and through further discussion with 28 VOLUME 5 ISSUE 1

3 providers involved in the cases before the PDR meeting. In addition to whether the unplanned transfer was preventable, the review included the case presentation, clinical decisions, type of diagnosis, communications documented in the electronic medical record, and portal of entry. Portal of entry is the location the patient was treated before admission and includes the ED, direct admissions, and scheduled admissions, including the OR. We excluded patients admitted from the OR to the floor for our primary analysis, because our purpose was to determine whether direct admissions are at increased risk of unplanned transfer and the alternative to a direct admission would be a stop in the ED for stabilization and assessment as to the appropriate location for admission. Thus, scheduled admissions are not a clinically relevant comparison. We also excluded patients with scheduled admissions for other reasons, such as from the infusion center or for planned tune ups or scheduled treatments. Direct admissions included admissions originating from clinics, ED, urgent care, and inpatient units located within the study institution s regional Network of Care (NOC) sites, outside facilities, and clinics within the study institution. The regional sites affiliated with our study institution are staffed by our institution s pediatric trained physicians. The inpatient units at these regional sites vary by location, and include community hospital models (with outside nursing and ancillary services) and freestanding facilities operated completely by the study institution s staff and physicians. We included our internal referral sites in the definition of direct admission because clinical deterioration en route is thought to be a risk for unplanned transfer after admission to the main campus facility, and our direct admission processes include patients coming from internal referral sites as well. The study institution serves as a referral center for a large geographic multistate region. The clinical chart review data and the decision of preventable versus nonpreventable, the reasons for preventable versus nonpreventable, and administrative data extracted from our electronic health record were collected and managed by using REDCap (Research Electronic Data Capture, an electronic data capture tool hosted at Children s Hospital Colorado). Institutional Direct Admissions Process Each direct admission was facilitated by the Patient Placement Department and the fellow or attending on the receiving service. The process of facilitating a direct admission at our institution during the time of the study is illustrated in Fig 1. The direct admissions process includes evaluation of vital signs and our institution s Pediatric Early Warning Score (PEWS) (Fig 2) before admission, assessment of the patient on arrival to the admitting facility, and communication algorithms to address patient status concerns during the direct admission process. Any referring physician requesting direct admission of a patient to our facility was directed to the Patient Placement Department. The call was initially taken by an admitting case manager (ACM, a registered nurse trained in InterQual criteria, a tool for utilization management decision support) who screened for appropriateness of direct admission, and identified the accepting service. The physician on call for the accepting service (fellow or attending, depending on service) was then connected with the referring physician and ACM by conference call. The clinical handoff took place, and the accepting physician either accepted the patient for direct admission or suggested a different disposition if indicated (eg, ED or PICU if patient not deemed appropriate for the ward). Criteria for determining appropriateness for direct admission to the ward included determination of a PEWS (based on patient vital signs at sending facility and clinical description by the sending provider, calculated by the ACM). Additional clinical information was used to determine appropriateness of placement as well, including mental status, work of breathing, progression of illness, or risk of worsening clinical status. These are all subjective measures that the accepting provider used to best determine appropriate patient placement. Once the patient arrived at our institution, he or she was met by a nurse (house supervisor, ED charge nurse, or admissions nurse) in our ED and another set of vital signs and PEWS was obtained and further brief clinical assessment took place by the registered nurse to confirm appropriateness of previously arranged transfer. If deemed appropriate for the floor, the patient was transported to the assigned bed. If the nurse initially assessing the patient was concerned about the appropriateness of direct admission to the floor, the nurse was empowered to notify the ED charge nurse and accepting physician, and redirect the patient to the ED for assessment and treatment. If a patient was triaged from an outside facility to the institution s ED, the patient 29

4 FIGURE 1 Study institution s direct admission process 2010 to was considered an ED admission for our study. Once a patient is on the inpatient ward, there is a 24/7 Rapid Response Team available to assess deteriorating patients and facilitate transfer to ICU if necessary. Statistical Analysis Descriptive statistics were calculated for early unplanned transfers. Differences in demographics and clinical characteristics were compared between preventable and unpreventable unplanned transfers by using χ 2 analysis or Fisher s exact test for categorical variables and Wilcoxon rank sum for continuous variables. Within the population of preventable early ICU transfers, the proportion of unplanned transfer from each portal of entry was calculated and compared with the overall proportion of admissions by using χ 2 analysis. The rates of nonpreventable early unplanned transfers from each portal of entry were also calculated and compared by using χ 2 analysis to determine whether direct admissions were more likely to result in an early unplanned ICU transfer than ED admissions. Analyses were performed by using SAS 9.3 (SAS Institute, Inc, Cary, NC). RESULTS Over the course of the 3-year study period, the hospital admitted patients. Of those admissions, 44% were admitted through the ED, 35% as scheduled admissions, including through the OR, and 21% directly admitted to the inpatient floor. The patients who were admitted 30 VOLUME 5 ISSUE 1

5 from the OR were excluded from our study, resulting in a total of patients analyzed. During the study, a total of 279 early unplanned transfers were identified and analyzed; 101 (36%) were classified as preventable unplanned transfers. There was no difference between direct admissions and ED admissions resulting in preventable early unplanned transfers to the ICU (P =.64). Demographic information, primary admitting diagnoses, and presence of comorbidities are presented in Table 1. Comorbidities included any additional chronic conditions patients had at the time of their admission. The rates of early unplanned ICU transfer per 1000 non-icu admissions were 3.50 for direct admissions and 3.18 for ED admissions (Fig 3). FIGURE 2 Study institution s PEWS. Please note: Patients with asthma on continuous albuterol nebulizers will automatically be a 3 due to respiratory status; please use clinical judgment and make sure the patient is meeting the criteria for not just tachycardia when rating the cardiovascular system. FIGURE 3 Rates of preventable and nonpreventable ICU transfer per 1000 admissions, by portal of entry. Preventable and nonpreventable cases were broken down into transfer reason (Table 2). PICU census near maximum capacity was listed when it was felt that limited bed availability in the PICU led to sicker patients being placed on the inpatient ward rather than the ICU. The other reasons include guideline nonadherence, equipment issues, anaphylactic reaction, difference in clinical assessment between providers, breath-holding spell, choking spell, medical error, and missing elements of patient history due to patient s altered mental status at the time of presentation and no parent available for additional history. Overall rates of preventable unplanned transfers were 3.40 in 2010, 3.37 in 2011, and 3.09 in 2012 (P =.91). The percentage of unplanned transfers that were preventable were analyzed based on the location of portal of entry, comparing Children s Hospital Colorado (CHCO) sites (main campus 31

6 TABLE 1 Gender, Ethnicity, Race, Primary Admitting Diagnoses, and Comorbidities Present for All Preventable and Nonpreventable Early Unplanned ICU Transfers Preventable Nonpreventable Overall cases n % n % Sex, boys Ethnicity, Hispanic Race Asian Black Native Hawaiian/Pacific Islander White Other More than 1 race Unknown Age, y, median (25%ile, 75%ile) 3.1 (0.67, 9.0) 3.4 (1.1, 8.8) Primary admitting diagnosis Acute respiratory illness, not asthma Apnea Neurologic Asthma Gastrointestinal/liver condition Bone fractures Other Comorbidities present Yes No Not listed FIGURE 4 Percentage of unplanned ICU transfers that were preventable by location of portal of entry. UC, urgent care; CHCO Main Campus Clinic, Children s Hospital Colorado main hospital outpatient clinic. ED, 35%; NOC sites, 28%; main campus clinics, 25%) and outside facilities (57%) and are shown in Fig 4. DISCUSSION Our study found that direct admissions did not have a higher rate of preventable unplanned transfer within 12 hours of admission to an inpatient unit compared with admissions from our institution s ED. Direct admission is thought to be a higher-risk population, but our data show that in our hospital system where direct admission processes are in place, there is no increased rate of early unplanned transfer. Due to the difference in assessment and flow of OR patients, we did not include unplanned transfers from the OR in our primary analysis. It has been long thought by many at the study institution that direct admissions have a higher rate of early unplanned transfer. This has been based on anecdotal evidence but no data existed in our organization to prove or refute this belief. This belief has led to numerous discussions encouraging the use of the ED for all direct admissions to provide another evaluation before admission to an inpatient bed. This has large resource utilization implications, as well as parent/caregiver satisfaction concerns. Unplanned ICU transfers have significantly increased mortality rates, greater severity of illness, and longer duration of ICU stays when compared with patients transferred directly from the ED or OR both in the adult and pediatric settings. 7 9 In our analysis, we felt that ED admissions were the most appropriate comparison group and thus compared direct and ED preventable early unplanned ICU transfers. 32 VOLUME 5 ISSUE 1

7 TABLE 2 Transfer Reasons for Preventable and Nonpreventable Unplanned Transfers Transfer Reason Preventable Nonpreventable n % n % Progression of illness Missed diagnosis Communication breakdown/miscommunication PICU census near maximum capacity Misplaced based on illness acuity Other reasons More than 1 reason could be assigned to each case; percentages do not total 100%. Another finding that deserves mention is that 36% of early unplanned transfers in our study were considered preventable, which presents a significant area for quality improvement. This was most commonly attributed to patients being misplaced to a lower level of care than they required. Although it is difficult to predict the clinical progression of a patient, this may represent a population of patients where risk factors can be further identified so that providers can consider a higher level of care. As described in the adult literature, progression of illness is clearly identified as the cause of many unplanned transfers; however, inappropriate placements and missed diagnoses may place patients at increased risk for cardiopulmonary arrest on the inpatient floor. 10 Bapoje et al 10 identified that 19% of the unplanned transfers to the ICU in the adult setting resulted from errors in care (with 52% of the error in care involving incorrect triage from the ED), and 15% of unplanned transfers were preventable. ICU data have shown that pediatric patients transferred from outside hospitals tend to be more critically ill and have longer lengths of stay. 2,11 Miscommunication was also a common cause for transfers deemed preventable in our study, with failure to escalate and lack of assertion as the most common reasons for miscommunication. Although providers or nurses may document concern within the medical record, they do not always practice assertion in communicating their concern for the need of higher-acuity care. Churchman and Doherty 12 note that nurses are unlikely to challenge doctors if they perceived that this would result in conflict or stress. This further substantiates the importance of effective assertion communication practices to prevent patient misplacement. The focus on evaluating early un planned ICU transfers at our organization has led to improvement initiatives. Improvements have been made to communication processes for patient placement. Each early unplanned ICU transfer that was found to be preventable resulted in quality improvement feedback to departments involved in the case. As a result of these findings, the hospital has put in place several initiatives to improve the direct ad mission process. These include standardizing the initial assessment process, improving handoffs, encouraging assertion practices, and improving documentation in the electronic health record. We also looked at the percentage of unplanned transfers that were preventable based on whether the site from where the care originated was at one of our facilities sites (main ED, NOC site, or clinic) or an outside facility. The percentage of early unplanned transfers that were preventable was nearly twice as high for patients whose care originated at an outside facility, suggesting that the knowledge of the system across our facility sites allows for more accurate triage and placement of patients to prevent preventable unplanned ICU transfers. Investigation of why there is marked disparity in these areas, including evaluation of causes of preventable unplanned transfer at each site, is a possibility for future study. There are a few limitations to this study. Early unplanned ICU transfer is an uncommon event, occurring in <1% of all admissions. This limited our study population to 279 patients over the course of 3 years and therefore may have limited our ability to detect a difference if it is truly present. It is possible that some of the patients who were routed to the ED and not directly to the floor were sicker than those who were directly admitted, which could have affected our results. Another consideration is the subjectivity associated with the PDR committee. We attempted to limit bias by including a wide range of patient placement team members from a variety of disciplines and departments. Despite the depth of the committee, personal opinions and experiences of the committee members undoubtedly influence the categorization of preventable versus nonpreventable. Also, the PDR committee was not blinded to portal of entry, so it is possible that there was a bias toward nonpreventable for patients entering our system from our own institution compared with outside institutions. In addition, the study 33

8 was conducted at 1 institution, with a large network of care and catchment area. This may limit the generalizability of the outcome because hospitals differ in their direct admission protocols and admission characteristics. Furthermore, we did not incorporate clinical characteristics into our analysis. These data are available and present the opportunity for further studies on clinical factors involved in early unplanned ICU transfers. Although our study did not identify clinical risk factors associated with early unplanned ICU transfer, the evidence in the literature suggests that these patients represent a group with higher morbidity, mortality, and resource use. Krmpotic et al 5 described clinical findings of pediatric patients who required early unplanned admission to the ICU. This will continue to be an area of future research. Unplanned ICU transfers are a significant source of potentially preventable risk to pediatric inpatients, and they may stress hospital systems already limited by other factors. Our study suggests that the risk of unplanned transfers for direct admissions in an institution where direct admission protocols are in place is not different from the risk of unplanned transfers from other admission sources. Although future multicenter trials will be needed to determine the comparative efficacy of implementing admission protocols, our study may lead other institutions to consider developing or improving direct admission protocols to reduce unplanned ICU transfers and improve safety for hospitalized children. REFERENCES 1. Odetola FO, Rosenberg AL, Davis MM, Clark SJ, Dechert RE, Shanley TP. Do outcomes vary according to the source of admission to the pediatric intensive care unit? Pediatr Crit Care Med. 2008;9(1): Gregory CJ, Nasrollahzadeh F, Dharmar M, Parsapour K, Marcin JP. Comparison of critically ill and injured children transferred from referring hospitals versus in-house admissions. Pediatrics. 2008;121(4). Available at: 4/e Frost SA, Alexandrou E, Bogdanovski T, Salamonson Y, Parr MJ, Hillman KM. Unplanned admission to intensive care after emergency hospitalisation: risk factors and development of a nomogram for individualising risk. Resuscitation. 2009;80(2): Escobar GJ, Greene JD, Gardner MN, Marelich GP, Quick B, Kipnis P. Intrahospital transfers to a higher level of care: contribution to total hospital and intensive care unit (ICU) mortality and length of stay (LOS). J Hosp Med. 2011;6(2): Krmpotic K, Lobos AT. Clinical profi le of children requiring early unplanned admission to the PICU. Hosp Pediatr. 2013;3(3): Delgado MK, Liu V, Pines JM, Kipnis P, Gardner MN, Escobar GJ. Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system. J Hosp Med. 2013;8(1): Goldhill DR, McNarry AF, Hadjianastassiou VG, Tekkis PP. The longer patients are in hospital before intensive care admission the higher their mortality. Intensive Care Med. 2004;30(10): Escarce JJ, Kelley MA. Admission source to the medical intensive care unit predicts hospital death independent of APACHE II score. JAMA. 1990;264(18): Hillman KM, Bristow PJ, Chey T, et al. Duration of life-threatening antecedents prior to intensive care admission. Intensive Care Med. 2002;28(11): Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J Hosp Med. 2011;6(2): Golestanian E, Scruggs JE, Gangnon RE, Mak RP, Wood KE. Effect of interhospital transfer on resource utilization and outcomes at a tertiary care referral center. Crit Care Med. 2007;35(6): Churchman JJ, Doherty C. Nurses views on challenging doctors practice in an acute hospital. Nurs Stand. 2010;24(40): VOLUME 5 ISSUE 1

9 Rate of Preventable Early Unplanned Intensive Care Unit Transfer for Direct Admissions and Emergency Department Admissions Jennifer Reese, Sara J. Deakyne, Ashley Blanchard and Lalit Bajaj Hospital Pediatrics 2015;5;27 DOI: /hpeds Updated Information & Services References Subspecialty Collections Permissions & Licensing Reprints including high resolution figures, can be found at: This article cites 11 articles, 1 of which you can access for free at: This article, along with others on similar topics, appears in the following collection(s): Quality Improvement ent_sub Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Information about ordering reprints can be found online:

10 Rate of Preventable Early Unplanned Intensive Care Unit Transfer for Direct Admissions and Emergency Department Admissions Jennifer Reese, Sara J. Deakyne, Ashley Blanchard and Lalit Bajaj Hospital Pediatrics 2015;5;27 DOI: /hpeds The online version of this article, along with updated information and services, is located on the World Wide Web at: Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2015 by the American Academy of Pediatrics. All rights reserved. Print ISSN: